roflumilast cream — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient has diagnosis of seborrheic dermatitis AND BOTH of the following:
• ONE of the following:
• • Tried and had an inadequate response to ONE topical antifungal OR ONE topical corticosteroid used in treatment of seborrheic dermatitis OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical antifungals and topical corticosteroids
• AND ONE of the following:
• • Has seborrheic dermatitis of the scalp OR tried and had an inadequate response to ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical calcineurin inhibitors
• Prescriber is specialist in area of diagnosis or has consulted a specialist
• Patient does NOT have FDA labeled contraindications

Reauthorization criteria

• Previously approved for the requested agent through plan’s PA process
• Has had clinical benefit with requested agent
• Prescriber is specialist in area of diagnosis or has consulted a specialist
• No FDA labeled contraindications

Approval duration

3 months